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TB Notes 1, 2000
Where We've Been and Where We're Going: Perspectives from CDC's Partners in TB Control
Changes I've Seen
TB Control in New York City: A Recent History
Not by DOT Alone
Baltimore at the New Millennium
From Crickets to Condoms and Beyond
The Denver TB Program: Opportunity, Creativity, Persistence, and Luck
National Jewish: The 100-Year War Against TB
Earthquakes, Population Growth, and TB in Los Angeles County
TB in Alaska
CDC and the American Lung Association/ American Thoracic Society: an Enduring Public/Private Partnership
The Unusual Suspects
The Model TB Prevention and Control Centers: History and Purpose
My Perspective on TB Control over the Past Two to Three Decades
History of the IUATLD
Thoughts about the Future of TB Control in the United States
Where We've Been and Where We're Going: Perspectives from CDC
Early History of the CDC TB Division, 1944-1985
CDC Funding for TB Prevention and Control
Managed Care and TB Control - A New Era
Early Research Activities of the TB Control Division
The First TB Drug Clinical Trials
Current TB Drug Trials: The Tuberculosis Trials Consortium (TBTC)
TB Communications and Education
TB Control in the Information Age
Field Services Activities
TB's Public Health Heroes
Infection Control Issues
A Decade of Notable TB Outbreaks: A Selected Review
International Activities
The Role of CDC's Division of Quarantine in the Fight Against TB in the U.S.
The STOP TB Initiative, A Global Partnership
Seize the Moment - Personal Reflections
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This is an archived document. The links are no longer being updated.

TB Notes 1, 2000

Thoughts about the Future of TB Control in the United States

by Charles M. Nolan, MD
Director, TB Control Program
Seattle-King County Dept of Public Health

It is gratifying, isn't it, to be back on the pathway toward TB elimination. I guess it's true that we who work in TB control had more prominence and visibility in the recent era during which TB was resurgent; a declining public health problem is never very newsworthy. Still, speaking personally, the satisfaction of watching the regular declines in US TB morbidity each year since 1992 exceeds the cheap thrill of being interviewed by local TV news personalities about the looming threat to our community of resurgent TB.

But what does the future hold for TB controllers? Will we continue to see our efforts rewarded by predictable declines in TB case numbers and rates into the indefinite future, until we finally arrive at our goal, the elimination of TB from the US? Even though we are good people, working toward a noble cause that we deserve to achieve, I submit that this optimistic view of an inevitable future decline of TB in the US is not necessarily our destiny. I fear that as we continue to work against TB in its current epidemiological expression in the US, we may be destined to reach a point at which the force of TB control is balanced by the force of the disease in our population. In that scenario, with neither opposing force having the upper hand, TB morbidity in the US will not continue to decline but will become level.

I am emboldened to hypothesize, in the absence of new factors in the equation, a forthcoming equilibrium between TB and TB control in the US, and a stabilization in the TB incidence rate in the US, because that is precisely what has happened in recent years in my community. The accompanying figure portrays the numbers of TB cases reported in Seattle-King County, Washington, and in the US from 1990 through 1998. Even though the numbers of cases represented in the two jurisdictions differ dramatically, the trend is unmistakable; during a period in which the TB morbidity in the US declined by 35%, that in Seattle-King County remained basically stable. (If annual incidence rates rather than case numbers had been presented, the trends would have been the same).

Image 1: Graph showing the Tuberculosis in Seattle-King County 1990-1998; Comparison with U.S. TB Morbidity.

Here is my explanation for the trends shown in the figure. At the national level, we are now reaping the harvest of reinvesting in good TB control. We have secured the necessary funding and have applied those funds strategically throughout the country to strengthen surveillance and case finding, to expand directly observed therapy for TB cases in order to increase completion rates and reduce acquired drug resistance, and to stop nosocomial transmission and other pockets of current transmission of TB.

Speaking in terms of a theory of TB control, our investment has allowed us to regain the ground that was lost during the resurgence by applying to their best advantage our current tools (this fact was noted in a JAMA editorial written in 1997 by Drs. Bess Miller and Ken Castro of the Division of TB Elimination). In that sense, the drop in cases and case rates nationally represent a reduction in "excess morbidity" that arose during the time when the national infrastructure was weakened in relation to the strength of the dual epidemics of TB and HIV, increased immigration from high-prevalence areas, and person-to-person transmission of TB, including nosocomial transmission.

Some places such as Seattle, however, did not experience the full power of the TB resurgence. For example, we were only modestly impacted by the HIV/TB phenomenon, with rapid person-to-person spread of disease, and MDR TB. Our infrastructure had not been dismantled, and we experienced less excess morbidity in those bad days. In the decade of the 1990s, however, even though we believe we have a good program structure, a talented staff, and funding sufficient to allow us to do good TB control work, we have failed to effect a meaningful reduction in TB morbidity in our community. In other words, we appear to have reached an equilibrium with our target disease, given its current epidemiological pattern in our community. This experience is the basis for my suggestion that it is possible that the nation as a whole will also reach such an equilibrium point, once its excess TB morbidity has been "mopped up." When that point may be reached, and at what level of morbidity, I of course cannot say.

I don't want to leave the impression that we have passively accepted the current status quo in Seattle. We are aggressively attempting to disrupt the equilibrium between TB and TB control by learning more about the epidemiology of TB in our community and by increasing the effectiveness of our community-based TB control plan. For example, in our community, persons born outside the US account for 70%-75% of cases, and RFLP survey data suggest that nearly all of our cases in foreign-born persons arise through reactivation of latent infection, including persons who have received preventive therapy. This information suggests that we need to expand treatment of latent TB infection in high-risk foreign-born persons; to accomplish that, we have established a Preventive Therapy Partnership Program with a number of health care facilities that provide primary health care to high-risk foreign-born persons. Also, given that we regularly see TB occur in foreign-born persons who have received preventive therapy in the past, we are reevaluating the traditional approach to preventive therapy, and have secured funding to develop new approaches to increase the uptake and completion of preventive therapy by newly-arrived immigrants and refugees.

Should the nation encounter such a "mud hole" in the road to TB elimination, similar strategies will be required to move beyond it. ACET, in its recent publication, TB Elimination Revisited: Obstacles, Opportunities, and a Renewed Commitment, has made several practical suggestions, including the need for every locale and/or state to understand the unique nature of its own TB problem, in order to apply current tools for TB control to their best advantage. The establishment of new partnerships to reach locally-identified high-risk groups is another important new concept.

Another way that an equilibrium between TB and TB control may become tipped in favor of TB control is by the introduction of new tools for the diagnosis, treatment, or prevention of TB. This point was also made by Dr. Miller and Dr. Castro in their JAMA editorial. Consider, for example, the advantage of being able to identify, among a population of 100 persons screened and found to have positive tuberculin skin tests, the handful that are destined to develop TB in the future, and to offer treatment only to those who are truly at risk, rather than to the entire cohort.

Likewise, based on forthcoming ATS/CDC recommendations, we now have a range of options for treatment for latent TB infection, which should result in more effective use of that preventive intervention. Finally, given the events of the past year, with burgeoning interest in a TB vaccine on the part of the US government, private philanthropic organizations, and the pharmaceutical industry, the notion of a TB vaccine at last (in the immortal words of Ken Castro) "passes the laugh test."

Even as Seattle's current impasse with TB has served to motivate us to redouble our efforts, to think creatively, and to engage new partners in our struggle, I am confident that, should our trend become a national one, the nation will be equal to that challenge. "The man (or woman) who is tenacious of purpose is not shaken from his firm resolve by the tyrant's threatening countenance." Horace, 23 BC.


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination -

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